J Endocr Surg.  2019 Sep;19(3):88-93. 10.16956/jes.2019.19.3.88.

It Sometimes Happens: Staging Surgery in Coexisting Graves' Disease and Thyroid Cancer

• Caruso E
• De Pasquale M
• Pino A
• Bartolo V
• Famà F
• Ieni A
• Dionigi G

• KMID: 2458707
• DOI: http://doi.org/10.16956/jes.2019.19.3.88

Abstract

Thyroidectomy is a safe procedure often performed either for benign or malignant thyroid diseases. Complication rate is low and bilateral recurrent laryngeal nerve (RLN) injury associated with thyroidectomy is rarely described. The RLN may be injured bilaterally and damage is usually recognized postoperatively. With an increased use of intraoperative neural monitoring (IONM), an adaptation of the resection strategy appears to be necessary in case of an intraoperative loss of signal of the first operated side with total thyroidectomy planned. We review a case of a 21-year-old female with a history of Graves' disease who underwent a total thyroidectomy in a 2-stage procedure due to a loss of RLN function detected intraoperatively. The patient recovered uneventfully from the 2 surgeries.

Keyword

Thyroid gland; Graves' disease; Laryngeal recurrent nerve; Injury

MeSH Terms

Female
Graves Disease*
Humans
Recurrent Laryngeal Nerve
Thyroid Diseases
Thyroid Gland*
Thyroid Neoplasms*
Thyroidectomy
Young Adult

Figure

• 

  Fig. 1 The clinical case presentation. Intraoperative evidence of first left RLN injury. Nerve lesion is not visible to surgeon's eye. Only EMG evaluation can confirm injury. Type 1 lesion (black arrow) was caused by excessive traction on the thyroid gland at Berry's ligament. RLN = recurrent laryngeal nerve.

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  Fig. 2 (A) Histology showed a well-differentiated neoplastic invasive proliferation with a diffuse follicular growth pattern, mainly constituted by microfollicles containing a small amount of colloid, with dense fibrotic septa without a tumor capsule (hematoxylin and eosin, ×20). (B) At higher magnification the tumor was composed by neoplastic elements with enlarged nuclei with typical papillary thyroid carcinoma features consisting of grooves, overlapping and clearing (hematoxylin and eosin, ×20).

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  Fig. 3 Surgical options for planned total thyroidectomy and intraoperative signal loss on the first operated side. LOS = loss of signal; RLN = recurrent laryngeal nerve.

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